**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, Incidents and Accidents (I&A) report review, and staff interview, it was determined the facility failed to ensure residents were free from abuse by other residents. This was true for 4 of 8 residents (#25, #30, #47 and #158) reviewed for abuse. This failure resulted in harm to Resident #47 when staff failed to supervise Resident #2 and he touched her breasts with his hands. Deficient practice also placed Residents #25, #30, #47 and #158, and all other residents in the facility at risk of psychosocial harm and/or physical harm. Findings include: The facility's policy and procedure, Protection of Residents: Reducing the Threat of Abuse and Neglect, revised 8/10/21, stated the facility practiced a hardline, zero-zero tolerance approach to resident abuse. The resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy defined the following: *Physical Abuse: including but not limited to hitting, slapping, punching, biting, and kicking. *Sexual Abuse: non-consensual contact of any type with a resident. Including but not limited to sexual harassment, sexual coercion, or sexual assault. This policy was not followed. 1. Sexual abuse of Resident #47 by Resident #2: *Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including dementia, major depressive disorder and cognitive communication deficit. A quarterly MDS assessment, dated 6/2/21, documented Resident #47 was severely cognitively impaired. *Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including dementia, hypertension and major depressive disorder. A care plan, initiated on 6/10/21, documented Resident #2 had a behavior problem of wandering related to dementia and the staff were directed to maintain line of sight supervision of him while he was up and out of bed. An I&A report, dated 8/4/21, documented Resident #2 entered the Activity Room. The Activity Director gave Resident #2 some cookies and he started to watch television. The Activity Director turned her head away from Resident #2, to take care of a couple of things prior to engaging Resident #2. Upon turning around, the Activity Director found Resident #2 had moved toward Resident #47 and touched her breasts with his hands. The Activity Director immediately intervened and separated the two residents. The facility's investigation of the 8/4/21 incident documented abuse was substantiated. On 12/2/21 at 3:11 PM, the Executive Director stated the direct line of sight to Resident #2 was not followed when the Activity Director turned away from Resident #2 for a brief period. The Executive Director said the Activity Director was provided with education regarding line of sight monitoring. The facility failed to ensure Resident #47 was free from sexual abuse. 2. Physical abuse by Resident #31 directed at Resident #25 and Resident #158: *Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder, hemiplegia (paralysis) and hemiparesis (weakness) on one side of the body following a stroke. A quarterly MDS assessment, dated 7/12/21, documented Resident #31 was moderately cognitively impaired and had no physical or verbal behaviors symptoms such as hitting, kicking, pushing, grabbing, threatening, cursing or screaming towards others. *Resident #25 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia (paralysis) and hemiparesis (weakness) on one side of the body. An annual MDS assessment, dated 8/5/21, documented Resident #25 was cognitively intact. *Resident #158 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including multiple sclerosis (a potentially disabling disease of the brain and spinal cord), cognitive communication deficit and diabetes mellitus. A quarterly MDS assessment, dated 8/10/21, documented Resident #158 was cognitively intact. An I&A report, dated 7/21/21 at 8:00 AM, documented Resident #31 punched Resident #158 on her shoulder in the dining room and was going to punch Resident #158 again when a CNA called his name. The Speech Therapist helped the CNA separate Resident #31 from Resident #158. After they were separated, Resident #31 was observed going after another resident. The CNA called the nurse and told the nurse what happened in the dining room. The nurse took Resident #31 and brought him back to his room. The nurse informed Resident #31 he could not go back to the dining room because he was trying to hit other people. The nurse instructed the staff members they needed to keep a close eye on Resident #31. An I&A report, dated 7/21/21 at 10:50 AM, documented Resident #31 was in the Activity Room participating in activities, when he approached Resident #25 and punched her in the nose. The I&A report documented Resident #25 thought she may have some bruising, but none had appeared at that time. Resident #25 was assessed and no injuries were noted. Resident #31 was subsequently transferred to the emergency room for evaluation related to his change in behavior The facility's investigations of the 7/21/21 incidents documented the incidents occurred and substantiated Resident #31 physically abused Resident #158 and Resident #25. On 12/3/21 at 8:11 AM, the Activity Director said she remembered the incident in the Activity Room when Resident #31 punched Resident #25's face. When asked if she was asked to keep an eye on Resident #31 while he was in the Activity Room or if she was aware of the incident in the dining room involving Resident #31 and the other residents, the Activity Director said she was not aware of the incident in the dining room and was not told to keep an eye on Resident #31 while he was in the Activity Room. On 12/3/21 at 1:32 PM, the Executive Director said Resident #31 had no history of physically hitting other residents in the facility. The Executive Director said they later found out Resident #31 became agitated when he was told by his family representative he would likely not be returning home and the facility was a great place for him. The Executive Director also stated the nurse was not told Resident #31 punched Resident #158 in the dining room, and it was a miscommunication between the staff. The Executive Director said staff were educated about proper reporting of abuse incidents. 3. Physical abuse by Resident #2 directed at Resident #30: *Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including hypertension (high blood pressure) and diabetes mellitus. A quarterly MDS assessment, dated 7/7/21, documented Resident #30 was cognitively intact. *Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including dementia, hypertension and major depressive disorder. A quarterly MDS assessment, dated 6/2/21, documented Resident #2 was severely cognitively impaired. An I&A report, dated 6/10/21, documented Resident #2 entered Resident #30's room uninvited. Resident #30 yelled at Resident #2 to leave her room. Resident #2 reached for Resident #30's overbed table and Resident #30 grabbed the table from him. Resident #2 then grabbed Resident #30's arm creating a scratch on her arm. Staff were able to intervene and redirect Resident #2. The facility's investigation of the 6/10/21 incident documented the incident did occur and Resident #30's physical abuse by Resident #2 was substantiated. On 12/2/21 at 3:11 PM, the Executive Director stated Resident #2 had no history of wandering prior to above incident. The Executive Director stated Resident #2's care plan was updated and directed staff to maintain line of sight supervision while he was up and out of bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, I&A report review, and staff interview, it was determined the facility failed to ensure adequate supervision of residents to prevent falls. This was true for 1 of 3 residents (Resident #23) reviewed for falls. This resulted in harm to Resident #23 when she had multiple falls and fractured her wrist and shoulder. Findings include: The facility's Fall Management policy, dated 6/4/20, documented the facility ensured the residents' environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents. Adequate supervision was defined as an intervention and means of mitigating the risk of accident. Resident #23 was admitted to the facility on [DATE], with multiple diagnoses including aftercare following a surgical procedure to repair a right femur (thigh bone) fracture, Lennox-Gastaut syndrome (a type of epilepsy with multiple different types of seizures, intellectual development is usually delayed and often worsens over time. Behavioral problems including hyperactivity, agitation, aggression and autism are common) intractable (hard to control), intellectual disabilities, difficulty walking, and repeated falls. A Fall Risk Evaluation, dated 6/24/21, documented Resident #23 was at high risk for falls. An admission MDS assessment, dated 6/30/21, documented Resident #23 had moderate cognitive impairment, she required extensive assistance of two persons with bed mobility, transfers, dressings and toileting, she was unsteady and only able to stabilize with human assistance when moving from seated to standing and when transferring from surface to surface, and she had fallen in the previous one to six months prior to admission to the facility. Resident #23's physician's orders included the following: * Seizure precaution. Keep vagus nerve stimulator (VNS - implanted to a patient and the patient will have a magnet that can be used at the time of the seizure), magnet at bedside and swipe the magnet past VNS if event occurs, ordered 6/24/21. * Clobazam (anti-seizure) 10 mg (milligrams) tablet, two times a day for seizure, ordered 10/31/21. * Tegretol (anti-convulsant) XR (extended release) 600 mg at bedtime for symptomatic epilepsy and epileptic syndrome, ordered 10/14/21. * Tegretol-XR 600 mg in the morning for symptomatic epilepsy and epileptic syndrome, ordered 10/22/21. Resident #23's care plan documented she had diffuse psycho motor delays (slowing of movement) and mild to moderate retardation, osteoporosis which resulted in multiple fractures and she was at risk for falls or had actual falls. Interventions included the following: * Initiated on 6/24/21: Assist Resident #23 with ADLs as needed, place her call light within reach, and complete fall risk assessment. * Initiated on 6/30/21: Educate Resident #23 that she is not strong enough to transfer self and that she needs to ask for assistance. * Initiated on 7/1/21: Anticipate Resident #23's needs and educate her family and caregivers about safety reminders and what to do if a fall occurs. Resident #23's I&A reports, dated 7/18/21 to 9/29/21, documented she had a total of 11 falls in 3 months, as follows: An I&A report, dated 7/18/21 at 9:10 PM, documented Resident #23 had an unwitnessed fall. Resident #23 reported she went to the bathroom using her wheelchair and did not lock the brakes of her wheelchair. Resident #23 picked herself up and reported the event to the staff. Resident #23's care plan was updated on 7/19/21, and directed staff to place anti-roll back bars on her wheelchair for safety. An I&A report, dated 7/23/21 at 11:00 AM, documented a CNA reported Resident #23 was noted on the floor in the hallway having a seizure. Resident #23 was assisted to bed after her seizure. The physician was notified and gave an order to obtain Tegretol level stat (immediately). A Physician's progress note, dated 7/23/21 at 11:24 AM, documented Resident #23 had an unwitnessed fall secondary to seizure. The progress note documented the facility staff reported Resident #23 generally was having seizures nightly. The physician gave an order to obtain Resident #23's Tegretol level. The physician also gave an order to increase Resident #23's Tegretol to 800 mg (milligrams) at bedtime and 600 mg in the morning. The physician documented based on Resident #23's records she had a history of frequent seizures especially at night. An I&A report, dated 7/29/21 at 1:30 PM, documented Resident #23 had an unwitnessed fall. She was found sitting on the floor between her bed and the window. Resident #23 reported she was getting up from her wheelchair to get her walker which was located across the room, the walker slid out from under her hands and she fell and bumped against the footboard. The I&A report documented Resident #23 did not use her call light to call for assistance. Resident #23's care plan was updated on 7/29/21, and directed staff to move her to a room closer to the nurse's station so that the staff could monitor her for safety, provide her with activities that would minimize the potential for falls, and provide diversion and distraction by encouraging her to attend activities and dine with other residents. An I&A report, dated 8/5/21 at 6:57 AM, documented Resident #23 had an unwitnessed fall. The nurse heard Resident #23 moaning and she was found on the floor beside her bed having a seizure. Facility staff used the VNS magnet to stop Resident #23's seizure and she was assisted to her bed. Resident #23 denied any pain from the fall. Resident #23's care plan was updated on 8/9/21, and directed staff to provide her with a lipped mattress to help her define the bed borders for safety. An I&A report, dated 8/14/21 at 3:00 PM, documented Resident #23 had an unwitnessed fall. A loud noise was heard from Resident #23's room and staff members found her on the floor beside her bed. The I&A report documented the bedside mat caused Resident #23 to trip and she fell on the floor. Resident #23's care plan was updated on 8/14/21, and directed staff to remove her fall mats during waking hours to avoid tripping hazard. An I&A report, dated 8/28/21 at 7:30 AM, documented Resident #23 had an unwitnessed fall. Resident #23 called out for help and staff found her on the floor lying on her back between the room's two beds. Resident #23 stated she was going to the bathroom. The I&A report documented the light in Resident #23's room was off when she had the fall. Resident #23's care plan was updated on 8/28/21, and directed staff to keep her night light on while sleeping in bed for safety. An Unusual Occurrence Report, dated 8/30/21 at 5:30 PM, documented Resident #23 was noted to have a bruise to her left arm the following day after her fall on 8/28/21. Resident #23 complained of pain which was effectively treated with Tramadol (narcotic pain medication). An order to X-ray Resident #23's left wrist was received, and revealed she had fracture on her left wrist. The Unusual Occurrence Report documented Resident #23 fractured her left wrist from the fall she had on 8/28/21. The root cause of the fall was related to her impulsivity and not using her call light, and when she attempted to be independent she might not be able to see clearly in a darker room. On 8/30/21 at 5:10 PM, a handwritten note documented an order was received to splint Resident #23's left wrist and refer her to an orthopedic physician. Subsequently, on 10/19/21, Resident #23 was seen by a physician in a hand center clinic and it was recommended to discontinue using the splint on her left wrist and she could use the wrist and thumb brace for comfort. An I&A report, dated 9/22/21 at 8:40 AM, documented Resident #23 had an unwitnessed fall. She was heard screaming from her room and when staff entered her room, she was on her knees on the floor between the window wall and her bed. Resident #23 was not wearing her slipper socks. Resident #23's care plan was updated on 9/22/21, and staff were directed place non-skid strips on the floor on the window side of her bed to help with traction and safety. On 9/24/21, staff were directed place a sign on her walker to remind her to take her walker with her when walking. An Unusual Occurrence report, dated 9/23/21, documented that at approximately 4:00 AM a CNA heard a commotion coming from Resident #23's room and checked on her. Resident #23 was found in her bathroom wearing five briefs. The one brief that was on the bottom was wet. The CNA redirected Resident #23 and removed the briefs and changed her. Resident #23 was reeducated to wear only one brief and assisted her back to bed. The CNA removed the remaining briefs from Resident #23's room. At approximately 4:50 AM, the CNA heard a commotion from Resident #23's room. When the CNA entered the room, Resident #23 rummaging through her roommate's drawers looking for more incontinence briefs. As the CNA walked in, Resident #23 repositioned herself by putting her hand on a can of nuts located on her over-bed table. The table rolled causing Resident #23 to lose her balance and fall on the floor onto her back and right shoulder. Resident #23 was assessed for pain and injury, and was assisted back to bed as she was not complaining of any pain. When the oncoming nurse checked on Resident #23, she complained of pain in her left shoulder. The nurse noted that Resident #23's left shoulder appeared to be out of socket. An order was received to perform an X-ray on Resident #23's left shoulder. The X-ray result, dated 9/23/21, showed a fracture on Resident #23's left shoulder involving the neck of the humerus (bone of the upper arm). The Unusual Occurrence report documented the root cause analysis of Resident #23's injury was her disabilities which led to her having an emotional outburst leading to poor choices. Resident #23 would often impulsively get up, being fiercely independent, lose her balance and fall. Resident #23 resisted redirection and often became angry when provided with 1:1 assistance. The Unusual Occurrence report also documented Resident #23 was very demanding for her independence, demonstrated behaviors that frequently compromised her safety, and when staff intervened her behavior frequently escalated. On 10/2/21, Resident #23 had a repeat X-ray of her left shoulder to compare with 9/23/21 result. The repeat X-ray result documented Interval displacement of the humeral neck fracture without healing demonstrated. An I&A report, dated 9/26/21 at 9:15 PM, documented Resident #23 had an unwitnessed fall. A loud bang was heard from Resident #23's room and when staff entered her room, she was found sitting on the floor by the privacy curtain. Resident #23's bedside table tipped over and there was water on the floor. Resident #23 stated she turned on her call light by mistake and she was trying to get up to turn it off. Resident #23's care plan was updated on 9/27/21, and staff were directed to move her roommate to another room, encourage her to keep her privacy curtain open for better line of sight, and to place a silent alarm to her bed and wheelchair to help notify the staff when she was getting up. Staff would carry the pagers with them. Staff were also educated on de-escalation of anger and emotional agitation. An I&A report, dated 9/29/21 at 3:00 PM, documented Resident #23 had a witnessed fall in her room. Resident #23 fell before the staff could reach her. Interdisciplinary Team reviewed the falls and decided to place a 1:1 (one to one) staff within line of sight supervision to manage Resident #23's safety. Resident #23's care plan was updated on 9/30/21, and directed staff to provide 1:1 line of sight supervision to her during waking hours and periods of agitation. On 11/16/21, a physician's progress note for Resident #23's follow-up check-up for her left shoulder fracture, documented her left shoulder's active range of motion was severely restricted and there was tenderness on palpation on her left shoulder. The physician's progress note also documented Resident #23 was not a good surgical candidate at this time. Resident #23 had to continue wearing her left shoulder immobilizer, as needed, for comfort and continue her physical therapy. Resident #23's record did not include documentation of additional falls after the initiation of 1:1 supervision. On 12/3/21 at 11:20 AM, the DON stated Resident #23 had multiple interventions to prevent falls in her care plan, and reviewed what those interventions were. The DON stated the 1:1 staff supervision for Resident #23 was not initiated earlier, such as after she fractured her left wrist from the fall on 8/28/21, as the interdisciplinary team thought it would make her behaviors worse. The facility failed to ensure Resident #23 received the level of supervision necessary to prevent falls, which resulted in a fracture of her left wrist from a fall on 8/28/21, and a fracture of her left shoulder from a fall on 9/23/21.